Board Vitals

Question 1

Which anti-inflammatory medication will not precipitate asthma symptoms in a Pt w newly diagnosed aspirin exascerbated respiratory disease (AERD)?

Answer 1

1. low dose aspirin (81mg)
2. high dose aspirin (1300mg)
3. ibuprofen
4. celecoxib

Question 2

A patient with spasmodic dysphonia seeks help from her otolaryngologist. Which of the following is most consistent with her condition?

Answer 2

A. Improvement in voice quality with sedativs such as benzodiazepines and alcohol

B. Voice quality is usually at its worst thing in the morning

C. Improvement in voice quality when talking on the telephone

D. Progressive worsening in voice quality with use, which may improve after rest

E. Voice quality does not change appreciably throughout the day

Question 3

A 32 year-old male presents to the ED with headache, spiking fevers, and unilateral facial pain. On exam, he is foudn to have significant inflammation and cellulitic changes surrounding his left nostril near the nasal sill. His left eye is proptotic and edematous and he is noted to have a left-sided lateral rectus palsy. Which of the following is the most likely diagnosis?

Answer 3

A. Preseptal cellulitis

B. Idiopathic intracranial hypertension

C. Acute sphenoid sinusitis

D. Meningitis

E. Cavernous sinus thrombosis

Question 4

A 52 year-old female presented to the clinic for the evaluation and treatment of cerumen impaction. However, during the examination, you calculate that the patient has a BMI of 32, and you note that she has Friedman IV tongue size and grade 3+ tonsils. Which of the following statements about the patient’s likelihood of having moderate-to-severe obstructive sleep apnea hypopnea syndrome (OSAHS) is corrent?

Answer 4

A. She has essentially zero risk of OSHAS because she has not volunteered any concerns regarding OSAHS symptomatology

B. She has an OSAHS score of 10 and a 90% chance of having moderate obstructive sleep apnea

C. She has an OSAHS score of 3 and a 70% chance of not having moderate-to-severe obstructive sleep apnea

D. She should be initiated on continous positive airway pressure (CPAP) therapy regardless of symptomatology or polysomnographic findings.

E. None of the above

Question 5

A 3.5 year-old boy with Down syndrome is brought ot his otolaryngologist for routine evaluation. The patient’s mother reports that he is doing well. She denies snoring or apneic episodes at night. She also denies changes in his gait or use of his arms and hands, neck pain, or torticollis. His most recent hearing test, perforemd six months ago, was normal. The patient’s TMs are poorly visualized due to canal stenosis. Which of the following is most appropriate?

Answer 5

A. Recommend polysomnogram

B. Follow-up in 1 year

C. Order lateral neck pain film

D. No further hearing test is needed

E. Recommend placement of tympanostomy tubes

Question 6

A patient is brought to the emergency department, and is profusely sweating and then starts seizing. His vital signs are as follows: Temp 103, HR 147, BP 205/110. EKG shows supraventricular tachycardia. You note that the patient has proptotic eyes. The patient has a medical history of Grave’s disease but admits that he does not take medications the doctors recommend. What therapeutic regimen is the appropriate management at this time?

Answer 6

A. Acetaminophen, propylthiouracil, iodine solution, propranolol, glucocorticoids, and cooling blankets

B. Acetaminophen, levothyroxine, iodine solution, propranolo, glucocorticoids, and cooling blankets

C. Propylthiouracil, lithium, propranolol, glucocorticoids, and cooling blankets

D. Iodine solution, propranolo, and cooling blankets

Question 7

Baker-Gorden phenol peel is:

Answer 7

A. Resorcinol 14g, salicylic acid 14g, lactic acid 14mL, ethanol 100mL; used for superficial peels

B. Resorcinol 14g, salicylic acid 14g, lactic acid 14mL, ethanol 100mL; used for deep peels

C. Phenol 88% 13cc, 2cc tap water, 8 gtts septicol, 3 gtt croton oil; used for superficial peels

D. Phenol 88% 3cc, 2cc tap water, 8 gtts septicol, 3 gtts croton oil; used for deep peels

Question 8

At 1 week following incision, what is the tensile strength of a wound compared to that of normal skin?

Answer 8

A. 3%

B. 30%

C. 50%

D. 60%

E. 80%

Question 9

A 45 year-old female presents with gradual hearing loss over the last 5 years. An ophthalmologist recently noted that her visual acuity difficulties were due to interstitial keratitis. What is the most likely diagnosis?

Answer 9

A. Cogan syndrome

B. Usher syndrome

C. Meniere’s disease

D. Vogt Koyanagi Harada syndrome

E. Presbycusis

Question 10

Which of the following statements regarding minoxidil is incorrect?

Answer 10

A. It is a vasodilator

B. It is a potassium channel (KATP channel) opener

C. It increases hair follicle size

D. It prolongs the telogen phase of hair growth and shortens the anagen phase

E. It may act as a nitrogen-oxide agonist

Question 11

During an elective neck dissection, the submandibular gland is dissected free of the overlying marginal mandibular nerve and the superior aspect is identified. The gland is delivered but upon closer inspection the submandibular ganglion appears to be transected. What symptom will this likely cause fot eh patient postoperatively?

Answer 11

A. Xerostomia

B. Hemitongue atrophy

C. Taste disturbance

D. Decreased tongue sensation

E. No symptoms

Question 12

A CT scan is performed on a 52 year-old female, and is shown below. What symptom most likely prompted this CT scan showing this benign, osteogenic tumor?

Answer 12

A. Epistaxis

B. Headache

C. Proptosis

D. Blurry vision

E. unilateral nasal obstruction

Question 13

What supplies the internal surface of the larynx?

Answer 13

A. Cricothyroid artery

B. Inferior laryngeal artery

C. Superior laryngeal artery

D. Thyroid artery

E. None of the above

Question 14

A 34 year-old male presents to you for evaluation of persistent right-sided tinnitus for 6 months. Examination of the ears is unremarkable. Audiologic testing reveals a unilateral normal sloping to moderate high frequency sensorineural hearing loss. MRI of the brainstem reveals a right cerebellopontine (CPA) lesion with evidence of growth compared to prior scans. The patient undergoes excision of this lesion with tissue analysis revealing the histiology shown. Which of the following is true regarding this patient’s diagnosis?

Answer 14

A. This tumor comprises approximately 50% of CPA tumors

B. High-resolution, contrast-enhanced MRI would reveal intermediate signla wiht marked enhancement with gadolinium with evidence of a dural tail

C. Hitselberger’s sign is the most common presenting symptom

D. CT-scan would likely show bony erosion and destruction of middle ear structure

E. None of the above

Question 15

A 3 month0old infant is referred to you for the evaluation of a right preauricular skin lesion (shown) that has quickly enlarged over the last 2 weeks. The lesion was not evident at birth per mother’s report. The patient is otherwise asymptomatic. Which of the following is true regarding the most likely diagnosis?

Answer 15

A. Biopsy would reveal cellular pleomorphism with nuclear atypia and scant cytoplasm with elevated mitotic figures

B. 50% of these tumors regress within the first 5 months

C. Tumor is likely to express Glut-1 transporter on immunohistochemistry

D. The infant is not an elevated risk for subglottic hemangioma

E. Observaiton is an inappropriate treatment decision in this case

Question 16

The majority of all cases of epistaxis occurs at the anastamosis of which four arteries?

Answer 16

A. Anterior ethmoid, posterior ethmoid, greater palatine, descending palatine

B. Superior labial, sphenopalatine, posterior ethmoid, posterior septal

C. Superior labial, anterior ethmoid, sphenopalatine, greater palatine

D. Posterior ethmoid, ascending pharyngeal, sphenopalatine, posterior septal

E. Ascending pharyngeal, posterior nasal, sphenopalatine, posterior septal

Question 17

The figure displayed shows the CT-sinus findings in a patient with allergic fungal rhinosinusitis (AFRS). Which of the following is not a Bent & Kuhn criterion for the diagnosis of AFRS?

A. Evidence of eosinophilia and Charcot-Leyden crystals in mucus
B. Presence of hyphal elements on fungal stain with vascular invasion
C. Evidence of type I hypersensitivity to identified fungal species
D. Nasal polyposis
E. CT-scan showing evidence of sinusitis with hypodense rim and hyperdense central material
F. B and D

Answer 17

B. Presence of hyphal elements on fungal stain with vascular invasion

Should not have vascular invasion. If so, then it is acute invasive fungal sinusitis (which is a surgical emergency)

Question 18

Which of the following apnea-hyponea indices (AHI) are diagnostic of moderate obstructive sleep apnea (OSA) in an adult?

A. 0 to 5/hour
B. 5 to 15/hour
C. 15 to 30/hour
D. 30 to 45/hour
E. 45 to 60/hour

Answer 18

C. 15 to 30/hour

Respiratory disturbance index (RDI) = apnea + hypopnea + repisratory-event-related arousals (RERA)

Apnea and hypopnea is for 10 secs

Mild OSA 5-15
Mod OSA 15-30
Severe >30

Question 19

A 14-year-old obese boy as recurrent episodes lasting up to 10 years, in which he sleep almost continuously throughout the day and night, waking only to eat and go to the bathroom. His mother reports that during these episodes he is in a bad mood. In between episodes he is a normal child. Which of the following is the most likely diagnosis?

A. Idiopathic hypersomnia
B. Narcolepsy
C. Klein-Levine syndrome
D. Untreated OSA syndrome
E. Delayed sleep phase syndrome

Answer 19

C. Klein-Levine syndrome

Klein-Levine syndrome is a type of recurrent hypersomnia. Recurrent episodes of hypersomnia that typically occur weeks or month apart. The onset is early teens, typically in males. The episodes can last for several days and sometimes weeks. Patients sleep for prolonged periods of time, 18 to 20 hours, waking only to eat and void. During these episodes, patients may have disrupted behaviors, such as irritability, aggressiveness, confusion, hypersexuality, and a voracious appetite.

Question 20

From what embryologic origin is the bony structure indicated by the arrow in the picture below derived?

A. First branchial arch
B. First branchial pouch
C. Second branchial arch
D. Second branchial pouch
E. Third branchial arch

Answer 20

C. Second branchial arch

The second branchial arch gives rise to the manubrium of the malleus, long process of the incus and the suprastructure of the stapes.

The first branchial arch gives rise to the malleus (except for the manubrium) and the incus (except for the long process).

Question 21

A 70 kg male patient is planning on undergonig a closed reduction of a nasal bone fracture in the office as he cannot afford going to the operating room. A regional block is planned of the infraorbital, supratrochlear, supraorbital, nasopalatine, and external nasal branch of the anterior ehtmoid nerve. A 30 gauge needle is utilized to minimize injection site discomfort. The solution of injection is prepared by the tech and labeled as 1% lidocaine wiht epinephrine. Negative pressure is applied to the syringe and no flash of blood is seen prior to injection. The block is started by beginning with the supraorbital nerve, the patient begins to complain of a metallic taste followed by nausea and vomiting after 3 cc was injected. What is the most likely etiology?

A. Intraluminal injection of local anesthesia
B. Incorrectly labeled concentration of lidocaine
C. Injection of lidocaine beyond its toxic dose
D. Failure to dilute the epinephrine appropriately
E. Vasovagal response

Answer 21

A. Intraluminal injection of local anesthesia

Lidocaine toxicity is manifested by neuro and cardiovascular toxicity. One of the earlier signs is metallic taste, tinnitus, and numbness around the mouth. As toxicity worsens further neurotoxicity can be seen with lightheadedness, nausea and vomiting, double vision, talkativeness, slurred speech, fine tremors and finally frank convulsions.

5mg/kg if no epi, 7mg/kg if epi

Question 22

A 57 year-old female presents to the clinic with an incidental finding of a 1.5 cm thyroid nodule. Patient denies dysphagia, dyspnea, and voice changes. An FNA is done which comes back as papillary thyroid carcinoma. The patient is taken to the operating room for a total thyroidectomy. To be a good thyroid surgeon it is essential to know the anatomic relationships for the external branch of the superior laryngeal nerve. What is the most common relationship of the external branch of the superior laryngeal nerve to the superior thyroid artery?

A. Ventral
B. Dorsal
C. Inferior
D. Lateral
E. Medial

Answer 22

B. Dorsal

The superior laryngeal nerve is one of the first branches of cranial nerve X as it exits the skull base at jugular foramen. About 1.5 cm caudal to the carotid bifurcation the superior laryngeal nerve (SLN) branches into internal and external branches of the SLN. The external branch of the SLN descends dorsal to the carotid sheath which then turns medial staying superficial to the inferior constrictor muscle. In its course the external branch of the SLN is most commonly dorsal to teh superior thyroid artery.

Question 23

Which of the following is true regarding osteoradionecrosis of the jaw in patients treated with radiation for oral cancer?

A. It rarely occurs in patients who have been exposed to a radiation dose less than 60 Gy
B. It is more common when brachytherapy is utilized
C. It is more common in patients treated for tumors of the larynx and pharynx, than it patients treated for tumors of the oral cavity
D. Maxillary osteoradionecrosis is more common than osteoradionecrosis of the mandible
E. The incidence with reirradiation is significantly higher than that seen during the initial course of radiation

Answer 23

A. It rarely occurs in patients who have been exposed to a radiation dose less than 60 Gy

The presentaiton of osteoradionecrosis (ORN) ranges from superficial, slowly progressive bone erosion, to pathological fracture. Patients often present with signs and symptoms of pain, crainage, fevers, and fistula formation. The incidence of ORN appears to be similar regardless of treatment technique and ranges from 5-7% with conventional RT, brachytherapy, of intensity-modulated radiation therapy (IMRT). However, the use of IMRT has been shown to reduce teh volume of the mandible exposed to radiation greater than >50 Gy and decreased rates of ORN (vs traditional radiation therapy) have been reported in multiple studies, although limited quality evidence makes it difficult to draw conclusions regarding IMRT’s real benefit on ORN risk reduction as compared to conventional radiation therapy.

Dental and periodontoal disease, poor oral hygiene, poor nutritional status, dental extractions, surgery, and trauma are frequently associated with the onset of ORN. ORN has also been reported to occur spontaneously. Although the risk of developing ORN is thought to be higher following treatment with combined chemo-radiation, to date there have been no studies that have conclusively shown an increase in the incidence of ORN in this patient population.

The risk of ORN with reirradiation is only silghtly higher than that seen during the initial course of radiaiton. This is thought due to small expansions in the reirradiation setting.

Question 24

A 3 year-old boy is brought to his otolaryngologist for evalution of his large tonsils and noisy breathing at night. Based on the history and physical, the patient is diagnosed with obstructive sleep apnea (OSA). Upon learning the diagnosis, the patient’s mother replies that her husband also has OSA and uses CPAP at night. Which of the following statements regarding adult and pediatric OSA is correct?

A. The male to female ratio is equal in pediatric and adult OSA?
B. Nocturnal arousals related to obstruction are rare in children but common in adults
C. Adenotonsillar hypertrophy is a common finding in children and adults
D. Mouth breathing is more frequent in adults wiht OSA than children
E. Daytime hypersomnolence is a common finding in both adults and children with OSA

Answer 24

B. Nocturnal arousals related to obstruction are rare in children but common in adults

Question 25

The internal nasal vale comprises what percentage of total nasal airway resistance?

A. 5
B. 10
C. 25
D. 50
E. 75

Answer 25

D. 50

The internal nasal valve is bordered by the septum medially, the anterior edge of the inferior turbinate inferolaterally, and the caudal edge of upper, lateral cartilage superolaterlaly

Question 26

Proton pump inhibitors:

A. Act on parietal cells, which secrete gastric acid and intrinsic factor.
B. Act on chief cells. They secrete pepsinogen.
C. Act on parietal cells. They secrete gastric acid and pepsinogen.
D.. Act on chief cells. They secrete gastric acid and pepsinogen.

Answer 26

A. Act on parietal cells, wihch secrete gastric acid and intrinsic factor

PPIs irreversible block parietal cell H+/K+ ATPase (gastric proton pump). The parietal cells are regulated by histamine, acetylcholine and other signals. Chief cells release pepsinogen and chymosin and are not the direct site of action of PPIs. Pepsinogen converts to its active pepsin form in an acidic environment.

Question 27

A 3 year old male is seen in the Emergency Department after swallowing an unknown amount of household cleaner that was stored in a soda bottle. On exam he is noted to be drooling with moderate erythema of the oropharynx. The solution was brought with the child and found to have a pH of 12. All of the following are reasons alkali solutions are more caustic than acidic solutions EXCEPT:

A. the esophagus provides a natural barrier to acid
B. alkali solutions cause coagulation necrosis
C. alkali solutions have higher permeability and thus penetrate depper into tissue
D. the esophagus has a slightly alkaline pH

Answer 27

B. alkali solutions cause coagulation necrosis

Alakali (basic) solutions cause liquefaction necrosis thereby penetrating deeper into the esophageal layers. This greatly increases the chance of esophageal perforation.

Question 28

An 18 year old presents to your clinic with complaints about her ears. She is found to have lack of an antihelical fold causing her to have a prominent cephaloauricular angle. You are planning on using a Mustarde suture for correction. How far apart should the medial and lateral limbs of each stitch be placed?

A. 10 mm
B. 12 mm
C. 14 mm
D. 16 mm
E. 18 mm

Answer 28

D. 16 mm

The Mustarde technique is a technique to correct the auriculocephalic angle. The normal angle is between 25 and 35 degrees. Anything greater than this is considered abnormal. The Mustarde technique involves removing an ellipse of postauricle skin and then placement of permanent horizontal mattress sutures wiht the medial and lateral limbs approximately 16 mm apart and tightened appropriately to recreate the fold. At least 3 sutures should be used to recreate the fold. The individual mattress stitches shoudl be 1-2 mm apart.

Question 29

A 25 year old male presents with painful inflamed folliculitis on the nasal tip. What nerve transmits pain from this region?

A. Internal nasal branch of anterior ethmoid nerve
B. Infratrochlear nerve
C. External nasal branch of anteior ethmoid nerve
D. Infraorbital nerve
E. Sphenopalatine nerve

Answer 29

C. External nasal branch of anterior ethmoid nerve

The internal nasal branch of the anterior ehtmoid nerve supplies the anterosuperior nasal cavity.

The infratrochlear nerve supplies the nasal dorsum.

The external nasal branch of the anterior ehtmoid nerve supplies the nasal tip

The infraorbital nerve supplies the malar area, lateral nose, and subnasal region

The sphenopalatine nerve supplies the posterior and inferior nasal cavity

Question 30

A 16 year old boy reports dizzines and weakness after beginning his immunotherapy. His blood pressure is 82/40 mm Hg. His pulse is weak and rapid. He weighs 49 kg. What dose and route of epinephrine 1:1000 should be used?

A. 0.3 cc IM
B. 0.3 cc IV
C. 1 cc PO
D. 1 cc IM
E. 1 cc IV

Answer 30

A. 0.3 cc IM

A dose of 0.3 cc IM is recommende dfor patients who weigh 25-50 kg. It may be administered every 5-15 minutes depending on the severity of symptoms. Higher dosages or IV administration may have adverse cardiac effects.

Question 31

A 55 year old male presents with the lesion pictured below. All of the following are contraindications to supraglottic laryngectomy except?

A. Vocal cord fixation
B. Involvement of the pyriform sinus above the plane of the laryngeal ventricle
C. Extensive base of tongue involvement
D. Bilateral involvement of the arytenoids
E. Thyroid cartilage invasion

Answer 31

B. Involvement of the pyriform sinus above the plane of the laryngeal ventricle

Involvement of the apex of the pyriform is a contraindication.

Question 32

This is a slowly growing mass in the upper left neck region of a 45 year-old male. What is the most probable 5 year survival rate of this lesion after adequate therapy?

A. 70%
B. 50%
C. 30%
D. 10%

Answer 32

A. 70%

This is a well differentiated (low grade) mucoepidermoid carcinoma. Low grade mucoepidermoid carcinomas typically have a 5 year survival of 70% when treated with gland excision and neck dissection for positive nodes only. The mucoepidermoid carcinomas form a spectrum of lesions with biologic behavior varying from almost benign to quite aggressive. It is important to histologically grade mucoepidermoid carcinomas.

Low grade lesions like this one are mainly glandular with abundant formation of glands and cystic spaces. Cytologic atypia is not seen. While local recurrence is possible metastases are rare.

High grade lesions are mainly squamous in histology with varying amounts of glandular tissue ranging from obvious to quite hard to find. Cell atypia will correlate with the
histologic grade. High grade mucoepidermoid carcinomas typically have a 5 year
survival of < 50% when treated with gland excision and neck dissection.

Question 33

What nerve palsies are present in Mobius syndrome?

A. CN V and VI
B. CN VI and VII
C. CN III, IV, V1 and VI
D. CN IX, X, and XI
E. CN X, XI, and XII

Answer 33

B. CN VI and VII

Mobius syndrome is rare congenital disorder of the rhomboencephalon (hindbrain). Cranial nerve palsies of VI and VII are core features of the syndrome, but otherwise the presentation of this syndrome can be very variable and include other cranial nerve palsies, craniofacial and limb abnormalities, and other neurologic dysfunction.

A 2019 systemic review of Mobius syndrome cases proposed 2 subtypes of Mobius syndrome

1. Micrognathia, limb anomalies, dysphagia
2. Radiologically detectable neurologic abnormalities, developmental delay

Question 34

What is the best audiologic test for an 8 month old child?

A. Conventional audiometry
B. Behavioral audiometry
C. Visual reinforcement audiometry
D. Play assisted audiometry
E. An 8 month old cannot be tested

Answer 34

C. Visual reinforcement audiometry

Behavioral audiometry 0-6 months (see any behavior w sound)
Visual reinforcement audiometry 6 months to 3 years
Play audiometry 3-5 years
Conventional 5-6 years

Question 35

Which of the following pathologies, if identified during parotidectomy, would require a neck dissection?

A. Epithelial-myoepithelial carcinoma
B. High-grade mucoepidermoid
C. Adenoid cystic carcinoma with involvement of the facial nerve
D. A 2.5 cm acinic cell carcinoma
E. Polymorphous low-grade adenocarcinoma

Answer 35

B. High-grade mucoepidermoid

The role of neck dissection for parotid pathologies depends largely on the nature of
the primary lesion. Generally speaking, a surgeon should be perform a neck dissection for the following indications:
1. Clinically apparent cervical lymphadenopathy (noted in approximately 14% of
parotid tumors).
2. Parotid tumors > 4 cm (risk of occult lymph nodes rises to >20% vs 4% for parotid
tumors < 4 cm in diameter, regardless of pathology).
3. For high-grade histology (risk of occult lymph nodes rises to >40% for high grade
lesions which include high-grade mucoepidermoid, squamous cell, and
adenocarcinoma, carcinosarcoma, and undifferentiated carcinoma).

Minor salivary gland tumors (MiSGs) have a higher cervical lymph node metastases rate than adenocystic carcinoma (ACC) of the parotid gland. The overall cervical lymph node metastases rate of MiSGs is 25%, which suggests that neck dissection might be beneficial to patients with ACC of MiSGs. A neck dissection is usually not necessary for adenoid cystic carcinoma of the parotid gland because the risk of cervical disease is low (4%) even in the presence of perineural invasion (which is common)

Question 36

A 10-year-old child is going to start an anti-thyroid medication. You are prescribing
methimazole, and the mother asks why you are not giving propylthiouracil (PTU). The
patient’s brother who is now 18 used PTU several years ago when he was hyperthyroid, and the mother says that PTU worked very well. Why are you not prescribing PTU?

A. There is a shortage of PTU in the United States.
B. Methimazole has a better cost-benefit profile.
C. PTU has an FDA boxed warning for acute renal failure and possible death.
D. PTU has an FDA boxed warning for severe liver injury, possible acute liver failure, and death

Answer 36

D. PTU has an FDA boxed warning for severe liver injury, possible acute liver failure and death.

Propylthiouracil (PTU) should not be used in pediatric patients unless the patient is
allergic to or intolerant of methimazole and no other treatment options are available.
Cases of significant liver injury leading to death or requiring liver transplant have
been reported with the use of PTU. PTU now has an FDA-issued boxed warning. For
pregnant patients in the first trimester, however, PTU is preferred due to the risk of
congenital defects with methimazole.

Question 37

A patient is being scheduled for radioactive iodine therapy. The Endocrinologist says she will continue thyroid hormone replacement therapy if she can assure availability of which of the following?

A. Adequate amount of I131
B. Adequate amounts of I123
C. Thyrogen (rhTSH-alpha)
D. Propylthiouracil

Answer 37

C. Thyrogen (rhTSH-alpha)

Elevated thyroid stimulating hormone (TSH) levels optimize the condition for radioactive iodine (RAI) uptake by cells. Patients were traditionally taken off their thyroid hormone supplementation several weeks prior to RAI. In 2007 Thyrogen (rhTSHα) synthetic TSH and Thyrogen (rhTSHα), was approved for use in patients for RAI therapy. When Thyrogen (rhTSHα) is used patients no longer have to come off thyroid hormone supplementation and hence hypothyroidism can be avoided.

Question 38

A truck driver sees his otolaryngologist for severe seasonal allergy symptoms. He is
interested in medication, but is concerned about the sedative effects. Which of the
following medications would treat his symptoms and is least likely to affect his ability to
work?

A. Diphenhydramine
B. Cetirizine
C. Hydroxyzine
D. Fexofenadine
E. Chlorpheniramine

Answer 38

D. Fexofenadine

First-generation histamine blockers are liphophilic and cross the blood brain barrier.
This characteristic leads to the sedative qualities. Diphenhydramine, hydroxyzine, and
chlorpeniramine are first-generation H1 blockers and would not be safe for use prior
to operating heavy machinery. Second-generation antihistamines are lipophobic and
do not cross the blood brain barrier. Cetirizine and fexofenadine are both H1 blockers
and are less sedating the first-generation medications. Even second-generation antihistamines have some sedative effects. Cetirizine has been shown to have as many as 3.5 times more likely to cause sedation as fexofenadine or loratidine.

Question 39

Which of the following is true regarding BRAF positivity in molecular testing of differentiated thyroid carcinoma?

A. BREF positivity is higher in those of follicular carcinoma than those wiht papillary thyroid carcinoma
B. There is a lower rate of cervical lymph node metastasis with BRAF positivity
C. BRAF positivity is associated with a higher TNM stage
D. BRAF positivity was associated with younger patients
E. BRAF positivity is primarily useful for assessing those with medullary subtype

Answer 39

C. BRAF positivity is associated with a higher TNM stage

BRAF mutations, particularly the V600E mutation, are associated with a more aggressive course and a higher TNM stage.

BRAF mutation is more common in those wiht papillary than follicular carcinoma. Associated with older patients. Not useful in medullary thyroid cancers.

Question 40

Which of the following is true regarding substernal multi-nodular goiters?

A. A thoracotomy is needed in about 25% of cases
B. Tracheomalacia is noted in 3% of cases
C. There is a higher rate of malignancy compared to the isolated thyroid nodule
D. If tracheomalacia is diagnosed intra-operatively, a tracheostomy should bypass the obstruction
E. Thyroid hormone will significantly decrease the size of multinodular goiters

Answer 40

B. Tracheomalacia is noted in 3% of cases

A. Transcervical incision is sufficient in the vast majority of cases.
B. Tracheomalacia is extremely rare (about 3% of cases performed in an iodine
deficient endemic goiter population).
C. Multinodular goiters have the same rate (around 5%) as isolated thyroid nodules.
D. The supra glottis and glottis are unaffected by the goiter, so placing an
endotracheal tube would have the same effect. Patients with multinodular goiters
seldom receive tracheostomies.
E. Although thyroid hormone may decrease the size of some iodine deficient goiters, it
has fallen out of favor as a treatment for multinodular goiters due to its poor
performance.

Question 41

An 86 year old female has been followed for five years for a right sided acoustic neuroma. She had moderate sensorineural hearing loss and grade II House-Brackmann facial nerve function. On recent MRI the lesion was noted to have increased 5mm over the past 12 months with a size of 2.5cm by 3.2cm. You explain that risks and benefits of surgery versus gamma-knife radiation given the significant increase in tumor size. What is a contraindication to gamma knife radiation in this patient?

A. age >75
B. serviceable hearing
C. grade II facial nerve function
D. size of tumor

Answer 41

D. Size of tumor

There are few contraindications to gamma knife radiosurgery but large cerebellopontine tumors (>3cm) may swell following radiation which can
lead to post-treatment obstructive hydrocephalus.

Absolute contraindications includes inferior spread of the tumor that is not adequately addressed by the collimator helmet. When discussing treatment with gamma knife radiation it should also be explained that gamma knife radiation does not cure the tumors but rather helps to halt growth thereby preventing further symptoms. Surgery may still be required if tumors progress despite radiation.

Question 42

A 69 year old male presents to the clinic with recurrent epistaxis from the right side with nasal congestion. Physical exam is consistent with a pigmented mass. Imaging shows the mass is located with the right nasal cavity originating from the paranasal sinuses. A biopsy is performed in the clinic which returns with the following information: 2.4 mm thick, vascular invasion present, ulceration present, 3 mitosis/high power field, perineural invasion present. Which of the following is the most well-defined prognostic factor in head and neck mucosal
melanomas?

A. Tumor depth of invasion
B. Site of origin in the head and neck
C. Ulceration
D. Mitotic index
E. Perineural invasion

Answer 42

B. Site of origin in the head and neck

One of the clearest, well-defined prognostic indicators in mucosal melanoma of the head and neck is the site of origin of the tumor, with a 5-year survival of 15-30% for the nasal cavity, 12% for the oral cavity, and 0-5% for the paranasal sinuses.

Question 43

Meckel’s cartilage is a derivative of which branchial arch?

A. 1st
B. 2nd
C. 3rd
D. 4th
E. 6th

Answer 43

A. 1st

Reichert cartilage is the second branchial arch derivative

Question 44

What are the results of augmenting and rasiing the radix?

A. Naso-frontal angle is unchanged
B. Naso-facial angle is more obtuse
C. Naso-facial angle is more acute
D. Naso-frontal angle is more acute
E. Naso-labial angle is more obtuse

Answer 44

C. Naso-facial angle is more acute

Augmenting the radix causes a downward rotation of the line measured from the nasion to the pronasale. Thus, the naso-frontal becomes more obtuse. The naso-facial angle becomes more acute.

Question 45

Which of the following accurately describes the ideal brow position in a woman?

A. Little to no brow arch
B. Highest point sits at the level of the supraorbital rim
C. Highest point occurs at the medial limbus
D. Medial brow head lies along a tangent with the medial canthus and nasal ala

Answer 45

D. Medial brow head lies along a tangent with the medial canthus and nasal ala.

In both men and women, the medial brow head lies along a tangent with the medial canthus and nasal ala, whereas the lateral brow head lies along an oblique line drawn from the nasal ala through the lateral canthus.

In women, the ideal shape displays the highest point of the brow arch above lateral limbus or lateral canthus, wiht the brow lying just above the supraorbital rim.

In men, the ideal brow has little to no arching and sits at the supraorbital rim.

Question 46

Hering’s Law should be considered when evaluating patients for which condition pre-operatively?

A. subclinical ptosis
B. subclinical facial nerve paresis
C. blepharospasm
D. vasomotor rhinitis

Answer 46

A. subclinical ptosis

Hering’s Law of Equal Innervation: Equivalent innervation of matched muscls may cause nonphysiological overactivity of the normal side while compensating for weak side; pertains to increased height of the eyelid on the normal side in response to blepharoptosis on the abnormal side.

Subclinical ptosis may be unmasked in the postoperative period after ptosis repair in the opposite eye. Subclinical ptosis can be detected in the preop eval by manually elevating the obviously ptotic lid. If Hering’s law is a factor, the opposite lid will become ptotic. The operative plan should include correction of ptosis for both lids.

Question 47

Nasal tip projection is decreased by which of the follwing maneuvers?

A. vertical dome division
B. inter-domal suture
C. lateral crural steal
D. complete transfixion incision

Answer 47

D. complete transfixion incision

The complete transfixion incision decreases nasal projection as it separates the central leg of the tripod (the paired medial crura) from the caudal septum thus causing the central tripod leg to settle inferoposteriorly towards the nasal spine. Another common maneuver that decreases nasal projection is the complete strip (or any other lateral crural weakening maneuver) as it weakens the lateral legs of the tripod.

Question 48

With regards to congenital cholesteatoma, which of the following is true?

A. There is a female to male preponderance of 2:1
B. Most congenital cholesteatomas are visualized as a white mass in the anterior-inferior quadrant
C. A history of otorrhea must precede the diagnosis of congenital cholesteatoma
D. The mean age of presentation is around the age of 4

Answer 48

D. The mean age of presentation is aroudn the age of 4

Question 49

A 39 year-old male presents for evaluation of chronic hoarseness. Laryngoscopy reveals a small sessile gray mass on the left posterior vocal cord. Biopsy of this mass reveals a pseudoepitheliomatous hyperplasia and stains positive for PAS and S-100. What is the diagnosis?

A. Hemangioma
B. Chondroma
C. Amyloidosis
D. Granular cell tumor
E. Papilloma

Answer 49

D: Granular cell tumor

Granular cell tumor is characterized as a small sessile gray mass. Histopathology reveals pseudoepitheliomatous hyperplasia and stains positive for PAS and S-100. They arise from Schwann cells in the posterior aspect of the true vocal cord and have a 3% risk of malignant degeneration.

Question 50

Which of the following components of gastric refluxate causes laryngeal epithelial cell damage at a neutral pH and may explain why some patients have refractory symptoms on maximal PPI therapy?

A. Gastric acid
B. Trypsin
C. Pepsin
D. Bile
E. Cholecystokinin

Answer 50

C. Pepsin

Pepsin is released by chief cells in the stomach and is important in protein digestion. It is maximally activd at pH 2 but has activity up ton pH 6.5. While inactive at pH 6.5 and above, it remains stable to pH 8. Thus when the pH in the larynx is reduced with reflux, pepsin can cause break down protein in laryngeal cells and cause damage.

Another therory is that pepsin is taken up by laryngeal cells and can become activated in the cells, leading to damage to mitochondria and Golgi.

Question 51

A 68 year-old female presents with a 4 month history of progressive weakness of her right shoulder when she tries to lift her arm over her head. A MRI scan is obtained as seen below. Which of the following physical exam findings would be expected in this patient?

A. Right side ptosis
B. Loss of facial sensation
C. Deviation of uvula to left
D. Right lower lip weakness
E. Right lateral gaze palsy

Answer 51

C. Deviation of uvula to left

The patient has a right side jugular paraganglioma. Lower cranial nerve involvement is frequent and occurs in 38-58% of cases. Multiple cranial nerves are involved due to location of the tumor in the jugular foramen. The most common nerves are cranial nerves 9-12. Vernet syndrome (paralysis of CN 9, 10, 11) or Collet-Sicard syndrome (CN 9-12) occurs in at least 10% of patients with jugular paragangliomas.

Uvula deviates to the opposite side of lesion

Question 52

A 6 year-old male with an normal external ear is being assessed for candidacy for surgical correction of congenital aural atresia. A CT of temporal bone is obtained and reveals a well-pneumatized middle ear space and mastoid, a normal oval and round window, a facial nerve, and a malleus/incus complex. There is no stapes or incus stapes-connection seen on CT. What is this patient’s score on the Jahrsdoefer grading system and is he a candidate for surgery?

Answer 52

7; he is a candidate for surgery

SOMEFIRMM

5 or less poor outcome

Question 53

A 35 year-old male presents with a 6 month of progressive right side nasal obstruction. Endoscopic exam reveals a pale, polypoid lesion emanating from the middle meatus obstructing the view of the middle turbinate. Biopsy of the mass is concerning for inverted papilloma. From which sinonasal site does inverted papilloma most frequently arise?

A. Maxillary sinus
B. Fontal sinus
C. Ethmoid sinus
D. Lateral nasal wall
E. Sphenoid sinus

Answer 53

D. Lateral nasal wall

Inverted papilloma is the second most common benign tumor of the sinonasal tract after osteoma. Endoscopy usually shows a pale, polypoid lesion with a papillary appearance that protrudes from the middle meatus. It most frequently arises from the lateral nasal wall int he fontanelle area and it is frequently related to the middle turbinate/middle meatus and maxillary ostium. The maxillary sinus is the most commonly affected sinus, and frontal and spheonid sinuses are rarely involved primarily. Often the lesion extensively involves more than one sinus, making it impossible to assess the exact site of origint.

Question 54

A 10 week old male comes into clinic for evaluation of facial infantile hemangioma. Patient is otherwise healthy. Physical exam shows normal heart rate and lung fields without wheezing. Given the size and cosmetic concerns, he is started on propranolol therapy. What is an appropriate starting dose?

A. 0.33 mg/kg PO q8hr x3 doses then increase to 0.66 mg/kg PO q8hr if tolerated
B. 0.33 mg/kg PO q8hr x3 dises then increase to 0.5 mg/kg PO q8hr if tolerated
C. 0.33 mg/kg PO q8hr
D. 0.33 mg/kg PO q6hr x3-7 days, then 0.5 mg/kg PO q6hr if tolerated
E. 0.33 mg/kg PO q8hr x3-7 days, then 0.66 mg/kg PO q8hr if tolerated.

Answer 54

D. 0.33 mg/kg PO q6hr x3-7 days, then 0.5 mg/kg PO q6hr if tolerated

If >8wks D. 0.33 mg/kg PO q6hr x3-7 days, then 0.5 mg/kg PO q6hr if tolerated

If <8wks A. 0.33 mg/kg PO q8hr x3 doses then increase to 0.66 mg/kg PO q8hr if tolerated

Pt who start therapy should be monitored closely with BP and HR cheks 1 and 3 hour after first 6 doses.

Question 55

A 35 year-old male presents for evaluation of a scar from a laceration on his forehead sustained in an ATV accident. He is very concerned about the appearance and after counseling consents to undergo dermabrasion. At a follow-up appointment 2 months later he has an improved appearance of the scar but he inquires about a second dermabrasion to further improve the scar appearance. What is the recommended time after the initial procedure to proceed with a second dermabrasion?

A. 3 months
B. 4 months
C. 6 months
D. 12 months
E. 18 months

Answer 55

D. 12 months

Patients with a prior hx of skin resurfacing tend to have a less dramatic result with dermabrasion and are at a slightly higher risk of hypopigmentation and complications. A minimum of 12 months is recommended before a second dermabrasion procedure to allow for maximal improvement of scars and completion of the healing process.

Question 56

A 35 year-old female with significant allergic rhinitis undergoes allergy testing showing reaction to ragweed. She elects to undergo intradermal immunotherapy. What ist he appropriate duration of therapy?

A. 1-3 months
B. 3-6 months
C. 6-12 months
D. 1-3 years
E. 3-5 years

Answer 56

E. 3-5 years

The treatment offers relif, but the onset of action is slow: improvement starts within 12 weeks and increases over a period 1 to 2 years after treatment. Because the treatment involves multiple visits, it requires a high degree of patient compliance. IT also has significant adverse effects, such as death.

In addition, SCIT is highly specific and effective only for the allergens administered, and it takes months to achieve clinical improvement; therefore careful identification of all allergens responsible for the patient’s symptoms before initiation of treatment is important. The duration of SCIT is usually 3-5 years.

Question 57

A 3 year old girl presents with a history of a rapidly enlarging and then persistnet right upper neck mass for the last six months, which has so far been refractory to clarithromycin. The skin over the top of the mass has a violet color. What is the best treatment option for this problem?

Answer 57

C. Complete surgical excision fo the mass

The lesion described is a nontuberculous mycobacterial disease (NTM). The disease mainly affects children younger than 5 years of age and in immunocompromised patients. The typical presentation is a rapidly enlarging and persistent parotid or neck mass that has failed to respond to antibiotic therapy. The skin becomes adherent to surroudning tissues and develops a violaceous discoloration. The treatment of choice is complete surgical excision of teh involved salivary gland and nodes.

Question 59

67 year-old male presents for evaluation of a left facial mass. He notes he had “Some type of tumor and surgery” performed there 8 year ago. On physical exam you note several nodular densities over the left parotid area fixed to the overlying tissue as well as a well-healed Modified Blair incision. There are no other suspicious lesions present in the oropharynx or skin. The patient does not have his pathology results available but he was told before he had a “benign” lesion at his first surgery. What is the likely diagnosis?

A. Recurrent pleomorphic adenoma
B. Carcinoma ex pleomorphic
C. Hodgkin’s lymphoma
D. Adenoid cystic carcinoma
E. Metastatic squamous cell carcinoma

Answer 59

A. Recurrent pleomorphic adenoma

If there is a violation of the capsule of the tumor during the original surgery and tumor spillage occurs it often recurs in multiple areas as is seen in this case.

Carcinoma ex pleomorphic occurs in a longstanding pleomorphic adenoma. The risk of malignant transformation is about 10%. Malignant parotid masses will frequently cause either pain or facial paralysis.

Question 60

Which of the following is true regarding the brachial plexus?

A. C5 and C6 roots merge to form the middle trunk
B. The dorsal scapular nerve arises from the C4 root
C. The middle trunk divides to form the lateral and posterior cords
D. The suprascapular nerve arises from the lower trunk
E. The posterior cord branches, giving rise to the axillary nerve which becomes the ulnar nerve

Answer 60

C. The middle trunk divides to form the lateral and posterior cords

A. C5 and C6 roots merge to form the upper trunk, while the C7 root forms the middle trunk

B. The dorsal scapular nerve arises from the C5 root

D. The suprascapular nerve arises from the upper trunk

E. The posterior cord branches, giving rise to the axillary nerve which becomes the radial nerve. The medial cord branches and contributes to the median nerve, which then becomes the ulnar nerve.

Question 61

A 15 year-old female swallows a bottle of bleach in a suicide attempt. Esophagoscopy performed at 24 hours shows circumferential burns. What is this patient at risk of developing in the future?

A. Adenocarcinoma
B. Neuroendocrine tumor
C. Barrett’s esophagus
D. SCC
E. Achalasia

Answer 61

D. SCC

Achalasia develops from failure of the LES to relax leading to dilation fo the proximal esophagus.

Patients with caustic ingestion are at a high risk for developing stricture of the esophagus, not dilation.

Question 62

A 56-year-old female with chronic rhinosinusitis is undergoing endoscopic sinus surgery. What clinical manifestation would you expect if the structure indicated was inadvertently injured during surgery?

A. Vision loss in the right eye
B. Loss of sensation below the eye
C. Left sided hemiplegia
D. Decreased nasal discharge

Answer 62

B. Loss of sensation below the right eye.

The arrow is pointing to the foramen rotundum on a non-contrast coronal CT. The foramen rotundum is identifiable as it is seen in cross ection on coronal films, as opposed to the foramen ovale, which is seen on the cross section of an axial cut

Question 63

The figure shown displays an example of isolated sphenoid sinus opacification (arrow). Which of the following statements is true regarding isolated sphenoid sinus diseases (ISSD)?

A. The incidence of ISSD is about a quarter of all sinus diseases
B. Less than 5% of ISSD cases are caused by an underlying primary sphenoid neoplasm
C. MRI demonstrates greater diagnostic sensitivity for fungal sinusitis compared to CT scan
D. Intractable headache is the most common presenting symptom of ISSD
E. Findings of bony erosion on CT are rarely associated with an malignant process

Answer 63

D. Intractable headache is the most common presenting symptom of ISSD.

Intractable headache is the most common symptom associated with ISSD (62%), followed by ocular symptoms such as visual disturbances (28%) or ophthalmoplegia (21%). CT scan demonstrates 100% sensitivity for fungal sinusitis due to traditional mottled appearance wiht calcifications and surroudning bony sclerosis (vs MRI 21%). Approximately 32% of ISSD cases harbor an underlying neoplastic proces,s 62% of which are primary sphenoid neoplasms (inverted papilloma and SCC) vs 38% due to extra-sinus tumor (pituitary adenoma, clival chordoma, lymphoepithelioma)